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June Marshall, DNP, RN, NEA-BCCole Edmonson, DNP, RN, FACHE, NEA-BC, FAANVictoria England, MBA, BSN, RN, NE-BC

Nurse Manager’s Guide to Retention & Recruitment

With the current nursing shortage, recruiting and retaining the best nurses has implications for all levels of practice and all care delivery settings. Nurse Manager’s Guide to Retention and Recruitment is a user-friendly guide for nurse leaders that provides sound theoretical perspectives, evidence-based practices, practical strategies, and tools for achieving the best recruitment, engagement, and retention outcomes for their organization.

In addition, this book includes examples gleaned from the authors’ collective years of experience and expertise in a complex urban healthcare market with large for-profit, not-for-profit, and public (county, state, and federally funded) healthcare organizations and systems.

Build and retain a high-performing nursing team through:

• Current evidence-based practice and expert opinion from • successful nursing leaders • Case studies and interactive problem-solving scenarios • Extensive bibliographies, appendixes, and additional • resources for further education

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Nurse Manager’s Guide to Retention & Recruitment is published by HCPro, an H3.Group division of

Simplify Compliance LLC.

Copyright © 2017 HCPro, an H3.Group division of Simplify Compliance LLC.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

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June Marshall, DNP, RN, NEA-BC, Author

Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN, Author

Victoria England, MBA, BSN, RN, NE-BC, Author

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© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | iii

Table of Contents

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Nursing Education Instructional Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Target Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1: Nurse Turnover: Realities, Risks, and Prevention . . . . . . . . . . . . . . . . . . . 1

Modern-Day Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Nurse Leaders, the Endangered Species of Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Costs of Turnover and High Vacancy Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Retaining Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 2: Embracing Diversity in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Types of Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Multigenerational Workforce Challenges and Opportunities . . . . . . . . . . . . . . . . . . . . . 13

Creating and Sustaining Diversity-Sensitive Care Environments . . . . . . . . . . . . . . . . . . . 16

Valuing Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 3: Developing Nurse Managers and Leaders as Chief Retention Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Leading by Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Onboarding and Ongoing Leadership Development . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Successful Recruitment, Candidate Selection, Interviewing, and Hiring . . . . . . . . . . . . 25

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Table of Contents

Managers’ Role in Building, Engaging, and Retaining High-Performing Nursing Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Chapter 4: Employee- and Family-Friendly Policies and Programs . . . . . . . . . . . . 33

Create an Environment of Care, Concern, and Respect . . . . . . . . . . . . . . . . . . . . . . . . . 33

Employee- and Family-Friendly Policies, Programs, and Practices . . . . . . . . . . . . . . . . . 36

Putting Ideas Into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5: Developing Professional Models of Care . . . . . . . . . . . . . . . . . . . . . . . . 43

From Theory to Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Chapter 6: Quality Improvement Systems and Workforce Retention . . . . . . . . . . 51

Relationships Matter: Quality and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Using Performance Improvement Strategies to Address Workforce Outcomes . . . . . . . 52

Create a Workplace Environment Council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Identifying, Monitoring, and Analyzing Metrics That Matter . . . . . . . . . . . . . . . . . . . . . . 53

Balancing Stability and Change: Weighing Risks and Benefits . . . . . . . . . . . . . . . . . . . . 55

Strategies for Recruiting and Retaining a Balanced Workforce—Addressing Current Needs While Planning for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Leadership Presence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter 7: Ensuring Interdisciplinary Collaboration . . . . . . . . . . . . . . . . . . . . . . . . 59

Communication: Emerging Technology and Team Strategies for Success . . . . . . . . . . 59

Changing Roles in Changing Times: The Importance of Collaboration to Achieve Desired Results and Patients as Partners in Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Capitalizing on Diverse Strengths and Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Matching Teams With Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Leading in Clinical Microsystems: Breaking Down Silos and Removing Power Gradients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | v

Table of Contents

Care Transitions and Teams Across the Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Chapter 8: Professional Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Role-Specific Professional Development—Embarking on the Leadership Journey . . . . 69

Developing Formal and Informal Leaders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Discerning Career Paths in Nursing: Developing, Engaging, and Retaining Best Talent and Finding the Best Role ‘Fit’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Career Enhancement Programs That Support Role Development . . . . . . . . . . . . . . . . . 76

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter 9: Recognition and Reward Programs That Promote Retention . . . . . . . 79

The Importance of Recognition and Reward Programs—Not Just About the Money! . . 79

Create a Plan for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Building the Business Case for Recruitment and Retention Programs . . . . . . . . . . . . . . 84

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Chapter 10: Establishing Academic Partnerships to Build a Successful Pipeline . . 91

Academic Partnership Programs: Assessing the Landscape and Selecting the Right Partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Partnering With High School Health Professions Programs . . . . . . . . . . . . . . . . . . . . . . . 93

Successfully Managing Student Affiliations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Forging Clinical Faculty Opportunities for Internal Staff . . . . . . . . . . . . . . . . . . . . . . . . . 95

Innovative Practicum Programs to Increase Students’ Exposure to Specialty Areas With Hard-to-Fill Positions/Vacancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Externships, Internships, and Residencies as Recruitment and Retention Strategies . . .97

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

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Table of Contents

Chapter 11: Power of Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Changing the Paradigm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

From Data to Wisdom: Making Sense of It All . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Strategic Planning Around the Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Workforce Planning Trends and Issues: Considerations for the Future . . . . . . . . . . . . . 105

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Chapter 12: Strengths and Opportunities: What Works and What Doesn’t . . . . . .107

Common Mistakes and How to Avoid Them . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Recipes for Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Learning From Industries Outside Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

What Employees Seek in ‘Best Places to Work’ Environments . . . . . . . . . . . . . . . . . . . . 111

Appendix: Additional Tools and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

Selecting the right candidates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Celebrating nurses’ accomplishments and contributions . . . . . . . . . . . . . . . . . . . . . . 115

Incentives Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Seeking employee feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | vii

About the Authors

Dr . Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN

Dr. Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN, has a career spanning two decades with

roles including clinical nurse, supervisor, manager, director, associate chief nursing officer, and his

current position of chief nursing officer. He is a fellow in the American Academy of Nursing and the

American College of Healthcare Executives and Nursing Executive Advanced Board Certified by ANCC.

He is a Robert Wood Johnson Foundation Executive Nurse Fellow Alum. He completed his BSN and

MSN at Oklahoma University College of Nursing and his Doctor of Nursing Practice (DNP) at Texas

Christian University. He is a contributor to the literature, locally and nationally, in the area of leader-

ship, succession planning, research, moral courage, nurse bullying, culture building, emerging global

health issues, and Magnet©. Edmonson is a speaker in academic and professional settings, locally and

nationally, on topics ranging from Magnet, research, leadership, succession planning, moral courage,

nurse bullying, customer service, chronic obstructive pulmonary disorder, genetics/genomics, emerging

global health issues, and the IOM future of nursing. He is the creator of two antibullying websites.

Edmonson is a true nursing advocate who believes, espouses, and actively works to create leaders

from the bedside to the boardroom, empowering them to lead. He creates environments where

nurses are valued, are respected, have integrity of practice, and clearly demonstrate their contribu-

tions at all levels. He has led two organizations to Magnet and Magnet redesignation in the DFW

area, one being the first to accomplish this in the area, and the second being the fourth to be redesig-

nated in Dallas, both as a Magnet Project Director and a Chief Nursing Officer. He has been a pri-

mary investigator and a coinvestigator on numerous national and local nursing research studies

ranging from Just Cultures to genetics/genomics competencies for nurses. He is a cocreator of the

genetics/genomics toolbox for the NIH/NHGP/NCI. He is a mentor to staff nurses and both emerging

and experienced leaders in healthcare, with his influence being felt outside of nursing. He was the

primary architect of the “Just Culture” created in a large facility in Dallas and continues that role as

the Safe Choices (Just Culture) Champion in his current facility, setting the foundation for the high-re-

liability transformation of the organization.

viii |Nurse Manager’s Guide to Retention & Recruitment © 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

About the Authors

Victoria England, MBA, BSN, RN, MBA, NE-BC

Victoria England, MBA, BSN, RN, NE-BC, is the director of the Office of Nursing Excellence,

overseeing the Magnet© accreditation in Dallas, Texas. In this role, she works with the executive

leadership team and direct care staff in promoting nurse excellence thoroughout the organization.

Nurse retention and recruitment is her passion within hospital and ambulatory settings. She supports

the professional nurse in both practice and policy as the past chair of governmental affairs committee

for Texas Nurses Association and a practice committee member. She stays current on global nursing

through her participation with Texas Team Coalition.

England is a local, national, and international speaker on nursing professional practice, quality, and

patient/family-centered care. Her professional involvement includes past vice president of Texas

Nurses Association, ANA Delegate, current president of the Dallas-Fort Worth Great 100 Nurse Recog-

nition, and executive board member of North Texas Organization of Nurse Executives. Her passion

for representing the professional nurse throughout Dallas-Fort Worth drove her to become a member

of the inaugural class of Nurses on Boards. England received a Master of Business Administration

from Amberton University and a Bachelor of Nursing from University of Texas at Arlington. She is

currently pursuing her Doctorate of Nursing Practice.

Dr . June Marshall, DNP, RN, NEA-BC

Dr. June Marshall, DNP, RN, NEA-BC, has a long, diverse career in nursing spanning more than

four decades. Her roles include direct care nurse, clinical nurse specialist, nurse entrepreneur and

consultant, educator, researcher, and nurse leader. Marshall received her BSN from Texas Woman’s

University, MS (Nursing) from Virginia Commonwealth University-Medical College of Virginia, and

Doctorate of Nursing Practice from Texas Christian University. She is certified as a Nurse Executive-

Advanced by the American Nurses Credentialing Center. Dr. Marshall has diverse experience from a

variety of healthcare settings, including freestanding children’s hospitals, large academic medical

centers, rehabilitation settings, community medical centers, and large healthcare systems. She has a

long history of professional association involvement, serving in various leadership roles in Texas

Nurses Association, North Texas Organization of Nurse Executives, and DFW Great 100 Nurses, Inc.

Dr. Marshall has tremendous commitment to excellence in nursing and has collaboratively led two

organizations to achieve Magnet© designation. She has served as a facilitator for nursing shared

governance councils, led Nursing Peer Review Committees for four organizations, and has long been

committed to advocacy for nurses. She has taught leadership development for nurse supervisors,

managers, and directors and serves as adjunct faculty for students in a DNP in a Nursing Administra-

tion program. Dr Marshall has numerous articles and presentations on a wide variety of clinical,

research, and leadership topics. Her passion is focused on creating and sustaining healthy work

environments for nurses that attract and retain the best and brightest nurses in all roles.

© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | ix

Nursing Education Instructional Guide

Target Audience

Nurse manager, assistant nurse manager, nurse leader, nursing director, VP of nursing, chief nursing

officer, charge nurse, patient care manager, ancillary services managers, staff educators, nursing

professional development specialists, staff development directors

Statement of need

With the current shortage of nurses in the system, recruiting and retaining the best has implications

for nurses at all levels of practice and across all care delivery settings. This book is a user-friendly

guide for nurse leaders which will assist with sound theoretical perspectives, evidence-based prac-

tices, practical strategies, and tools for achieving the best recruitment, engagement, and retention

outcomes for their organization.

Educational objectives1. Identify megatrends in nursing

2. Understand costs and risks

3. Identify interventions to impact turnover and break the cycle

4. Identify types and significance of workplace diversity

5. Describe strategies for addressing generational workforce challenges

6. Assess and manage diversity-related workforce issues

x |Nurse Manager’s Guide to Retention & Recruitment © 2017 HCPro, an H3.Group division of Simplify Compliance, LLC


7. Identify key recruitment and retention leadership competencies

8. Describe successful candidate interview and selection strategies

9. Explain methods for engaging and retaining best talent

10. Describe important elements in employee-friendly workplace policies

11. Explain practices that promote healthy work-life balance

12. Identify strategies that promote manager-employee relationships and build trust

13. Build programs based on employees’ feedback and needs

14. Understand theoretical grounding for professional models of care—theory and reality

15. List key components of professional practice model

16. Discuss shared governance—employees’ roles in shared decision-making

17. Describe building and sustaining healthy interprofessional team relationships

18. Apply frontline leadership as an engagement strategy—ownership of professional practice

and outcomes

19. Discern the relationship between quality outcomes and workforce retention

20. Use performance improvement strategies to address workforce outcomes

21. Identify, monitor, and analyze metrics that matter

22. Balance stability and change while weighing risks and benefits

23. Implement strategies for recruiting and retaining a balanced workforce, addressing current

needs while planning for the future

24. Explain the role of emerging technology in team communication

25. Describe strategies for success in interprofessional team collaboration

26. Identify the role of individual strengths and styles in high-performing teams

27. Implement interprofessional collaborative teamwork within clinical microsystems, through care

transitions, and across the continuum

28. Identify role-specific professional development paths

29. Describe strategies for developing formal and informal leaders

30. Explain the importance of professional development in engaging and retaining nurses

31. Align career enhancement programs to support professional role development

32. Describe important elements of staff recognition in the workplace

33. Identify ways to reward staff

34. List essential aspects of the performance review that enhance retention

35. Identify strategies that promote manager-staff relationships

36. Identify strengths in academic partners to best match service organization needs

© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | xi


37. Define strategies for attracting high school students into healthcare careers

38. Explain key components in managing affiliations with academic partners

39. Explore models that provide opportunities to increase faculty resources

40. Describe mechanisms for academic-service partnership programs to support recruitment

and retention

41. Focus on retention rates instead of measuring turnover—risks and opportunities

42. Monitor local, regional, and national trends—finding meaning in the metrics

43. Use metrics in strategic planning to meet unit, department, and organization workforce needs

44. Understand workforce planning trends and issues—considerations for the future

45. Explain two common mistakes in recruiting and retaining the best employees

46. Understand key strategies for successful recruitment and retention

47. Identify best practices in industries outside healthcare

Faculty

June Marshall, DNP, RN, NEA-BC

Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN

Victoria England, MBA, BSN, RN, NE-BC

Accreditation/Designation statement

HCPro is accredited as a provider of continuing nursing education by the American Nurses Creden-

tialing Center’s Commission on Accreditation.

This educational activity for 3.5 contact hours is provided by HCPro, a division of BLR.

Nursing contact hours for this activity are valid from October 1, 2017 – October 1, 2020.

Disclosure statements

The planners, presenters/authors, and contributors of this CNE activity have disclosed no relevant

financial relationships with any commercial companies pertaining to this activity.

Instructions

In order to successfully complete this CNE activity and be eligible to receive your nursing contact

hours for this activity, you are required to do the following:

xii |Nurse Manager’s Guide to Retention & Recruitment © 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

Chapter

1. Read the book: Nurse Manager’s Guide to Retention & Recruitment

2. Go online to www.hcpro.com/downloads/12635

3. Follow the CE Instructional Guide

4. Complete the exam and receive a passing score of 80% or higher

5. Complete and submit the evaluation

6. Provide your contact information at the end of the evaluation

A certificate will be emailed to you immediately following your submission of the evalua-

tion and successful completion of the exam. Please retain this email for future reference.

NOTE

This book and associated exam are intended for individual use only. If you would like to provide this

continuing education exam to other members of your nursing staff, please contact our customer

service department at 800-650-6787 to place your order. The exam fee schedule is as follows:

Exam quantity Fee

1 $0

2–25 $15 per person



101+ $5 per person


© 2017 HCPro, an H3.Group division of Simplify Compliance, LLC Nurse Manager’s Guide to Retention & Recruitment | 1

1

Nurse Turnover: Realities, Risks, and Prevention

Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN

Modern-Day Healthcare

Today’s healthcare system is hallmarked by complexity, com-

plexity that is best described as increasing and more rapid

change than perhaps any other time in history. It is an exciting

time to be in healthcare, especially to be a nurse. Opportunities

abound, needed transformation is happening, and change is

afoot. The change is fueled by the effects of the increasing

percentage of gross domestic product that is unsustainable, the

Affordable Care Act (and its possible replacement), the growing

technology area, the tidal wave of the aging population, increas-

ing life span and chronic illness burden in an already overbur-

dened system with a growing shortage of healthcare providers,

restrictions that prevent professions from practicing at the top of

competency, increasing violence against healthcare workers, and

the lifestyle choices being made by providers that exaggerates

the growing access point and availability shortages.

The graying and greening of the nursing workforce is in full

effect, with many studies showing 20% under the age of 30 and

more than 75% are baby boomers and Generation X (Stokowski,

2013). The impending retirement wave and brain drain stands to

LEARNING OBJECTIVESAfter reading this chapter, the learner should be able to:

• Identify megatrends in nursing

• Understand costs and risks

• Identify interventions to impact turnover and break the cycle

2 |Nurse Manager’s Guide to Retention & Recruitment © 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

Chapter 1

worsen the nursing shortage, skill mix, tenure mix, and potentially the safety of patients. We are

entering what will be one of the most severe nursing shortages we have seen in decades. The Health

Resources and Services Administration (HRSA) workforce for nursing study projected an excess of

registered nurses (RN) by 2025 of 340,000. However, many leading authorities and nursing organiza-

tions have criticized the study for failing to take into account numerous model changes and using a

microsimulation model that forecasts an excess, among other issues. Many states have now created

their own forecasts attempting to correct for the HRSA model assumptions. For example, Texas Center

for Nursing Workforce Studies (2016) is forecasting a shortage of 59,770 nurses by 2030. Our most

valuable assets in healthcare will become even scarcer, and impact on patients and communities will

be seen in the quality of, access to, and availability of care, if we don’t reverse the trend and address

the issues that are driving nurses out of nursing.

The prevalence of workplace violence, ranging from incivility to physical abuse, is increasing in

society, and hospitals and health systems reflect this trend. In one survey of Texas nurses, over 82%

had experienced some form of workplace violence, with the most frequent occurrence being verbal

abuse, and the most frequent source being the people we are called to care for, patients (Texas

Center for Nursing Workforce Studies, 2016). One cannot deny the quandary this places on nurses,

who answer a calling to care for and help others but then suffer from abuse. Workplace violence has

many consequences for providers, systems, and patients. Nurses who experience incivility and

bullying exhibit signs of stress, ranging from an attention deficit to depression and can even result in

suicide. The consequence to health systems is in increased turnover, loss of talent, loss of productiv-

ity, and unstable patient care systems. The consequence to patients can be mistakes, errors, and

medical misadventures. Health systems can’t achieve High Reliability Organization (HRO) status with

these behaviors present.

Nurses need to think STEEP (social, technology, economic, environmental, and political drivers of the

future), like a futurist (Sommers, 2013). If we are working, living, and planning for today, we will

miss the opportunity to create the future and influence it. Working in the time-horizon like a futurist

is critical to knowing where and what to do ahead of trends. STEEP represents an opportunity for us

to think differently and use new optics. Sometimes just putting on a new hat or seeing through a

new lens can bring different thinking on old issues.

Nurse Leaders, the Endangered Species of Nursing

Dr. Mackoff, in her book Nurse Manager Engagement from Theory to Practice (2010), interviewed 23

high-performing nurse managers to understand not only the characteristics that they shared that

helped make them successful but also those that made them resilient. What emerged from the work

was the positional distance created by moving one’s career away from the bedside into leadership,



and the emergence of a emotional mastery curriculum that could be taught to improve resilience and

effectiveness. The nurse manager is perhaps the most stressful and impactful nurse leader position in

the organization. This nursing leadership role is, however, often in the middle management structure

that assigns heavy accountability, deep responsibility, and often little authority. Despite knowing the

impact of leaders on staff recruitment and retention, most organizations do not truly empower the

position or support the nurse manager, which results in the turnover rate ranging from 33 to 56%

among this group. This community of practice must be supported by providing resources, increasing

authority, offering reasonable spans and scopes, and expanding leadership education if the organiza-

tion is to succeed.

Costs of Turnover and High Vacancy Rates

Price-Waterhouse-Coopers (2017) estimated that every percentage of increase in a hospital’s annual

turnover rate costs the hospital $300,000. According to Kerfoot (2015), RN turnover costs for a spe-

cialty nurse and for a highly specialized nurse is $82,000. Costs for new-graduate nurses are even

higher when you consider the additional costs of training for residency, didactic, etc. First-year

turnover is particularly impactful and costs more, as the organization does not have the ability to

spread out the initial investment over a longer time period, generally producing a low return on

investment (ROI). For example, in a 300-bed hospital with 14% turnover, costs are estimated at $4.4

million (Kerfoot, 2015).

High vacancy rates increase the need for premium labor in organizations, and it can cause patient

admission losses and destabilize patient care systems with a potential increase in medical misadven-

tures (Hunt, 2009). Stresses on the system can increase absenteeism and presenteeism, according to

Hunt. Absenteesim is the regular practice of being away from the worksite without good reason.

Presenteeism is the problem of employees being on the job but, because of illness or other medical

conditions, not fully functioning. Both can be symptoms of larger problems. It is critical to seek out

and to validate the true causes of turnover and other issues that affect it. Organizations collect data

but tend to be information challenged, as most of the data is in separate surveys, databases, or

information silos. Nurse leaders need dashboards that monitor metrics sensitive to turnover and the

health of the environment in which nurses are practicing. One organization’s CNO created a dash-

board for civility that allowed the measuring of the civility index in individual units and the hospital

itself, using existing measures that we know to be sensitive to turnover, either directly or by proxies.

Creating the civility dashboard (www.stopbullyingtoolkit.org) allowed for nurse leaders to directly

measure the environment, looking for opportunities and for positives wins that could be harvested to

support the appreciative inquiry framework of the organization.


Chapter 1

Retaining Nurses

What do nurses want? What keeps nurses engaged? What can we do to decrease turnover?

Assuming leaders know what nurses want is dangerous. Leaders should turn to the literature and

evidence on recruitment and retention for the top issues but be skeptical that it is generalizable to

your population of nurses as a whole. Leaders should systematically find ways to engage the clini-

cians and nurse leaders in their organization to ask, as the responses from those key stakeholders

may be different from the evidence, based on many unique factors in their organizations. Contextual-

izing the interventions is important to the environment, the population, the resources, and the issues

in each facility. In a recent focus group of 70 nurses from a three-time Magnet® Designated Hospital

in the southwest with a 27-year history of shared governance, they identified the factors most import-

ant in retention. They are:

• Professional/personal development

• Sensitivity to life-work balance (develop quality-of-life initiatives [Kerfoot, 2015])

• Shared governance—voice and impact (high autonomy associated with improved retention

[Kovner, Djukic, Fatehi, Fletcher, Brewer, & Chacko])

• Drive to continue education by organization (BSN associated with improved retention

[Kovner et al.])

• Quality of care and outcomes

• Teamwork

• Flexibility (adapt) of care

• High levels of collaboration (interprofessional)

• Loyalty to employees—take care of employees

• Residency program (transition to practice)

• Attention to detail (compliance) and ethics

• Diversity and inclusion (modeling of caring behaviors)

• Innovation supported—evidence-based practice

• Approachable MD colleagues (respect) (positive relationships with physician improves reten-

tion [Kovner et al.])

• Safety (education) skills



Breaking the cycle

As a chief nursing officer (CNO), I have always said to new and current nurses: “If you like the

culture you find here, help keep it; if you don’t, help change it.” If culture is a keeper of people,

then people are the keepers of that culture. Culture is fluid and changing, just like living organ-

isms. They can be influenced and impacted by internal or external forces that are subtle to crisis

level in nature. The one constant is change, but even in the ever-changing world, we can have

anchors that hold us; these are values, morals, and ethics that can point us to our true north. Any

work on culture must start from an understanding of the norms, beliefs, and values that exist in

the current state; it must recognize and honor the past, and it must value and understand the

relationships that exist. Leaders must learn from the past, not be hostage to it, be willing to help

people leave it behind, and go with a sense of safety and direction into the future. Lewin’s model

of change (1947) with unfreezing, neutral zone, and refreezing is a pragmatic way to understand

and help guide change. Leaders need bold and compelling visions of the future, and they must

be able to translate these visions into inspiration. It is important to understand that leaders have

most often reached the end point of the cycle (refreezing) while those that follow them are just

beginning to move and accept the change (unfreezing). But perhaps the real danger is in the

neutral zone, where people feel rudderless, untethered, and unsure of the future and have a

tendency to seek safety in the familiar.

Any interventions or programs to retain clinical and nonclinical staff must not only understand

this but wrestle with the possibilities, over-communicate, and answer the WIIFM question

(What’s in it for me?). If we think about Maslow’s (1962) hierarchy of need and apply it to reten-

tion, it looks a lot like Figure 1.1.

FIGURE 1.1 TRIANGLE FIGURE BASED ON MASLOW

Source: Maslow’s Recognition graph, *Bersin, Josh, (2013). Importance of Recognition Maslow’s Hierarchy 21st Century Talent Management: The New Ways Companies Hire, Engage, and Lead.

Source: Maslow’s Recognition graph, *Bersin, Josh, (2013). Importance of Recognition Maslow’s Hierarchy 21st Century Talent Management: The New Ways Companies Hire, Engage, and Lead.


Chapter 1

Voice/impact – Professional governance (self-actualization)

Professional development (self-esteem)

Positive work environment (love and belonging)

Safe workplace (safety and security)

Competitive pay/benefits (physiological needs)

Gracious space

• WOW Rounds – Night rounds by the leadership team once per month. Bring a meal and give

the staff time away from the unit, while the leaders take care of the unit.

• Midnight Munchies – Senior leadership should make it a routine to engage with night shift

staff on the night shift. Round with the purpose of recognizing, rewarding, and learning. It

doesn’t hurt to bring snacks, both healthy and sweet.

• Sacred Sixty – Protected rounding time for leaders with patients, staff, visitors, and physicians.

Authentic presence is powerful; everyone wants a leader that can be related to and trusted.

• Civility – Use the stop bullying toolkit available at www.stopbullyingtoolkit.org to create an

environment that is bully free. Implement antibullying education for leaders and staff. Imple-

ment a policy or add to a safe work place policy the zero tolerance for such behaviors across

organizations for employees, leaders, and physicians.

• Inspired Nurse – Find and translate work into your facility like Rich Bluni’s (2009) The

Inspired Nurse, which is 27 spiritual stretches for nurses that includes gratitude, telling your

story, and looking for the positive.

• The Pickle Pledge (2016) by Bob Dent and Joe Tye – Creates a fun challenge to improve the

work environment, while creating a charitable focus for the employees.

Safe space

• High Reliability – Create an environment where clinicians know what to expect, are involved

in creating it, and preventable serious safety events are zero. Provide tools and a culture that

embraces speaking up.

• “Just Culture” – Create a safe space for staff that doesn’t blame, scapegoat, or retaliate and

improves reporting of events and near misses that treats employees justly and fairly.

• Reflection Program – Hardwire reflection into practice using protected time for reflection, medi-

tation rooms, debriefing, Critical Incident Stress Management (CISM), and Schwartz rounds.



• Professional Practice Model – Select a professional practice model to guide practice that

embraces interprofessional practice and professional (shared) governance and support it

from the top.

Create a shared vision of the future with clinicians and leaders that aligns with the mission and vision

of the organization.

Bring the outside in. Many organizations are entropic, but like living organisms, we need external

sources, information, and stimuli. Bringing outside experts from other industries, authors, speakers,

and best practices can be a powerful positive influence.

People don’t leave organizations; they leave leaders. Focus on selecting the right leaders and then

providing ongoing education and training in leadership. Leadership and clinical are two different

domains of knowledge and expertise that need to be developed. Learning labs by Dr. Barbara

Mackoff are a powerful way to create a self-sustaining community of practice for leaders.

Appreciative space

• Standing Ovations – Use recognition liberally and often with an appreciative framework,

emphasizing the positive and managing the negative.

• Culberson’s book Do It Well: Make It Fun (2012) – Add new dimensions of fun to any

work place.

• Traveling Trophies – Find the positive deviants and spread the best practices. Create a pro-

gram for units to recognize one another for collaboration, collegiality, and positive contribu-

tions that required teamwork.

• Local/National Awards – Nominate nurses for facility, local, and national awards. If you don’t

have facility awards, create them using your mission, vision, values, and professional practice

model as a framework.

• Advancement – Provide career paths for nurses, career advancement programs, mentoring

programs, and preceptor programs.

• Self-Care Model – Create or implement a program of self-care for nurses. Nurses are excellent

at giving care to others and sometimes have little left for their own self-care. Giving structure,

resources, and permission to be selfish sometimes is powerful in achieving harmony in body,

mind, and spirit. As powerful as it is to implement a program, build it with sustainability;

don’t make it a flavor of the month. LeAnn Thieman’s SelfCare for Healthcare (2016) is one

such program.


Chapter 1

Nursing has long been recognized as important but often silent to the value of the contributions.

Payment models, lack of data, and hierarchies are but a few of the issues identified that may

prevent full recognition of the nursing value to not only cost avoidance and quality improve-

ments but also revenue streams. The age of team science and the study of how individuals

within teams and teams themselves produce better outcomes are just emerging. The Institute of

Medicine’s Future of Nursing Report (2010) began a critical dialog in the nursing profession,

healthcare, and business communities about not only the transformation of the profession, but

the greater contributions possible to create cultures of health. Think of the eight recommenda-

tions from the report as nursing’s professional determinants of creating a culture of health for all

Americans. These eight recommendations are defined in Box 1.1. It is a prime time for nursing to

lead in the interprofessional space, learn about team science, and place value and data to support

it upon the role of the nurse at all levels in the organization, system, community, and nation.

BOX 1.1: INSTITUTE OF MEDICINE’S FUTURE OF NURSING RECOMMENDATIONS

1. Remove scope of practice barriers

2. Expand opportunities for nurses to lead and diffuse collaborative improve-ment efforts

3. Implement nurse residency programs

4. Increase the proportion of nurses with a BSN to 80% by 2020

5. Double the number of nurses with doctorates by 2020

6. Ensure that nurses engage in lifelong learning

7. Prepare and enable nurses to lead change to advance health

8. Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data

Nurses have an obligation to patients, families, and communities to work to improve health and

health outcomes. Framing the issue of recruitment and retention as a moral obligation to stabilize

and improve systems of care is one expression of our ethics as nurses. Clearly, nurses will not be

retained in toxic environments, or with low-quality providers, or in organizations that do not

support their core values. Leaders and clinicians, along with educators, must work together to

create environments that attract and retain nurses on behalf of the profession and the patients

that every year vote nurses the most trusted and ethical profession in the Gallup Poll (2016).



References

Bluni, R. (2009). The Inspired Nurse. Gulf Breeze, FL. Firestarter Publishing.

Culberson, R. P. (2012). Do It Well. Make It Fun: The Key to Success in Life, Death, and Almost Everything in Between. Austin, TX: The Key Green Leaf Books.

Dent, B., & Tye, J. (2016). Pickle Pledge: Creating a More Positive Healthcare Culture – One Attitude at a Time. Paradox Twenty One Inc.

Health Resources and Services Administration: The future of the nursing workforce: national and state level projections 2012-2015. Retrieved from www.healthworkforceta.org/wp-content/uploads/2015/02/HRSA_2012_2025_Nursing_Projections.pdf.

Hunt, S. (2009). Nursing Turnover: Cost, Causes and Solutions. Retrieved from www.successfactors.com.

Institute of Medicine. (2010). Future of Nursing Report. Retrieved from www.ncbi.nlm.nih.gov/books/NBK209872.

Kerfoot, K. (2015). Health and Hospital Networks Four Measures that Are Key to Retaining Nurses. Retrieved from www.hhnmag.com/articles/3253-four-measures-that-are-key-to-retaining-nurses.

Kovner, C. T., Djukic, M., Fatehi, F. K., Fletcher, J., Jun, J., Brewer, C., & Chacko, T (2016). Estimating and preventing hospital internal turnover of newly licensed nurses: A panel survey. International Journal of Nursing Studies, Volume 60, 251–262.

Lewin, K. (1947) “Frontiers of Group Dynamics,” Human Relations, Volume 1.

Marx, D. Patient Safety and Just Culture. Retrieved 3/1/2017 from www.unmc.edu/patient-safety/_documents/patient-safety-and-the-just-culture.pdf.

Mackoff, B. (2010). Nurse Manager Engagement from Theory to Practice. Jones & Bartlett. New York, NY.

Maslow, A. H. (1962). Towards a Psychology of Being. Princeton: D. Van Nostrand Company.

PriceWaterhouseCoopers (2007). What works: healing the healthcare staffing shortage. PriceWaterhouseCoopers, LLP.

Sommers, C. (2013). Think like a futurist: Know what changes, what doesn’t and what’s next. San Francisco, CA: Jossey-Bass.

Stokowski, L. (2013). The 4 Generation Gap in Nursing. Retrieved from www.medscape.com/viewarticle/781752_2.

Texas Center for Nursing Workforce Studies. Nursing Supply and Demand Projections, 2015-2030. Retrieved from www.dshs.texas.gov/chs/cnws/Nursing-Workforce-Reports.

Thieman, L. (2016). SelfCare for Healthcare. Retrieved from www.selfcareforhealthcare.com.

116 | Nurse Manager’s Guide to Retention & Recruitment © 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

Additional Tools and Resources

details from this innovative program that might be adapted to your work setting. What a great way to

celebrate these clinical nurses and recognize their significant contributions and accomplishments!

Several examples of professional recognition awards are those given by professional nursing associa-

tions and honor societies (American Nurses Association, Sigma Theta Tau, and specialty associations

such as the American Association of Critical Care Nurses); local, regional, and national publications (e

g. Nurse.com, Modern Healthcare, and others); alumni awards from universities; and The DAISY

Award from the DAISY Foundation. When nurses are nominated for these awards by their peers and/

or leaders in an organization, they have a sense of pride and feeling valued by colleagues, regardless

whether they actually win the award.

One example of community recognition is presented in Case 2. Nurse leaders in the greater Dallas-

Fort Worth Community began a community recognition award more than 25 years ago. Given the

competitive nature of this large urban environment, nurse executives, leaders, and direct care staff

alike have embraced this opportunity to recognize and celebrate the accomplishments of nurses in all

roles. Each year 100 “GREAT” nurses are selected to receive this honor at a ceremony attended by

leaders, colleagues, friends, and family. While knowing that a peer or leader nominated them to

receive such an honor is meaningful and that they were selected from hundreds of nominations is

rewarding enough, but the loud cheering and support from their leaders and team members that

takes place at this event certainly plays an important role in fostering recipients’ loyalty to their

colleagues, their leaders, and their organizations.

Incentives Index

Most organizations periodically survey their nursing (and other) employees to seek feedback on

current incentive programs. One structured tool for gathering input from employees regarding com-

pensation and non-compensation-related incentives is the Incentives Index in Tool 2 (HCPro, Inc.).

While nurse managers have limited ability to address compensation-related incentives, there a num-

ber of non-monetary incentives that can be implemented for no, low, or minimal costs. Personal

attention and recognition from managers, flexible scheduling options, and team social activities are

examples of strategies that require time, effort, and commitment on the manager’s part, but do not

require financial resources to implement. Such incentives as these can contribute significantly to

employee retention.



Seeking employee feedback

Most employee and nursing satisfaction/engagement surveys are done no more than once a year. That

practice opens doors for nurse managers to implement other methods of tapping into employee

preferences and feedback. Such feedback can be gathered in a variety of ways, including open

forums, focus groups, staff and/or unit council meetings, face-to-face meetings with individuals or

small groups, suggestion boxes, or informal surveys. Some topics to consider including in focus

group questions and informal surveys are included in Tool 3.

TOOL 1 SAMPLE PERFORMANCE OR BEHAVIOR-BASED INTERVIEW TOOL

ANCC Magnet Recog-nition Program® (MRP) components, organiza-tion priorities, and job description

Resume or CV and goal(s)

Interview question Scoring [1-2-3-4-5] with notes on strengths and weaknesses:

1= Does not exhibit characteristics

2= Minimally exhibits characteristics

3= Satisfactory

4= Strongly exhibits characteristics

5= Exceeds characteristic expectations

Transformational leadership:

Uses the organization’s values, beliefs, and be-haviors to lead people to where they need to be

Has the applicant held any leadership roles?

(Examples: supervisor, lead nurse, charge nurse, preceptor)

Goal: A professional who motivates and energizes others to take on a vision and assume responsibility to make it happen

I see from your resume that you have been a [insert specifics here]

If a leadership role is not noted on the resume, ask for an example of a time the person assumed a leadership role. Then ask the following question.

Role question

Can you think of a time when you were a [name the leadership role] and someone you were working with was struggling with a new policy/procedure/change? How did you help them make the transition?

Score: 1 2 3 4 5

Strengths

Weaknesses

continued



TOOL 1 Sample Performance or Behavior-Based Interview Tool (cont.)

Structural empowerment:

Finds the best way to accomplish the organiza-tional goals and achieve desired outcomes

Is there evidence on the application or résumé that the applicant has been on an organizational task force, committee, or shared governance council?

Goal: A professional who understands organizational goals and steps to reach desired outcomes

Committee question

Committees exist to solve problems. Can you tell me about a problem your committee worked on? What was the solution recommended? How did the committee go about making this decision? Did this solution work? Why or why not?

If the person has not been on a committee, ask him or her to recall a time that a change in practice was communicated to the staff. What was the change? Why was the change need-ed? How did it go?

Score: 1 2 3 4 5

Strengths

Weaknesses

Job description Exemplary professional practice

Understanding the role of the profession per their profession’s scope and standards of practice

How long has the applicant been in the role? Does the applicant hold a professional certifica-tion? Is the applicant a member of a profes-sional organization?

Goal: A professional who can articulate the concepts of pro-fessional practice as it applies to his or her specialty area

Membership question

I see that you are a mem-ber of [insert organization here]. What have you gained professionally from being a member?

Certification question

If the person is not certified: I see that you do not hold a professional certification. Is this something you plan to pursue? Why or why not?

Score: 1 2 3 4 5

Strengths

Weaknesses



continued

continued

Job description

Uses clinical judgment to address patient care

Clinical judgment model (Tanner, 2006; Modic, 2013)

Noticing

Interpreting

Responding

Reflecting

Goal: A professional who can describe the process he or she uses to address changing clinical situations

Patient care scenario

Recall a time when you cared for a patient who was unstable. How did you know he or she was unstable? What did you notice? What about this information made the patient unstable?

What independent actions did you take? What patient care interventions needed to happen?

How did the situation turn out? (Reflection)

Score: 1 2 3 4 5

Strengths

Weaknesses

Job description

Exemplary professional practice

Application of the role of the [nurse, physician, pharmacist, physical therapist, etc.] with patients, families, and communities

Membership on com-mittees with a patient care focus (e.g., eth-ics, patient education, support groups)

Goal: A professional who acts on the behalf of a patient or community

Goal: A professional who is willing to speak up when an ac-tion (or lack thereof) compromises patient safety, quality care, or is incongruent with the patient and community needs

Patient and community education question

I see that you are/were a member of [insert specific here]. Can you tell me about a project/situation that the committee addressed? How did the committee meet the needs of the patient/com-munity?

Patient advocate question

Can you recall a time that you had to advocate on behalf of a patient (or community)? What was the situation? What did you do? How did it turn out?

Score: 1 2 3 4 5

Strengths

Weaknesses





Job description


Works as a member of the healthcare team to develop an interprofes-sional and interdisciplin-ary plan of care

Goal: A professional who can balance re-sponsibilities, values, knowledge, skills, and goals about patient care against his or her role as a team member in shared decision-making

Interdisciplinary team question

Recall a time when you provided care to a patient with a complex condition. Describe how the inter-disciplinary team worked together to care for the patient.

What went well? What could have been better?

Score: 1 2 3 4 5

Strengths

Weaknesses

Job description

Manages conflict using professional communica-tion skills

Goal: A professional who can identify why conflicts might occur on the healthcare setting (e.g., complex system with multiple decision-making points, professional role or scope of practice differences, ethnic diversity, and personal value differ-ences, etc.)

Goal: A professional who can identify effective and inef-fective strategies for addressing conflict (e.g., avoidance, com-petition, accommo-dation, compromise, collaboration)

Conflict resolution question (colleague)

Recall a time that you encountered a difference of opinion with a colleague. Describe the situation. What was the root cause of the conflict? What strategies did you take to resolve the conflict? Was it effective? Why or why not?

Conflict resolution question (patient)

Recall a time when a patient or family member was not pleased with his or her care. Describe the situation. Why do you think he or she was unhappy? What did you do? How did it turn out? In retrospect, was there anything that could have been done differently to keep this conflict form happening?

Score: 1 2 3 4 5

Strengths

Weaknesses





continued

Job description

Uses clinical judgment to address patient care

Clinical judgment model (Tanner, 2006; Modic, 2013)

Noticing

Interpreting

Responding

Reflecting

Goal: A professional who can describe the process he or she uses to address changing clinical situations

Patient care scenario

Recall a time when you cared for a patient who was unstable. How did you know he or she was unstable? What did you notice? What about this information made the patient unstable?

What independent actions did you take? What patient care interventions needed to happen?

How did the situation turn out? (Reflection)

Score: 1 2 3 4 5

Strengths

Weaknesses

Job description


Application of the role of the [nurse, physician, pharmacist, physical therapist, etc.] with patients, families, and communities

Membership on com-mittees with a patient care focus (e.g., eth-ics, patient education, support groups)

Goal: A professional who acts on the behalf of a patient or community

Goal: A professional who is willing to speak up when an ac-tion (or lack thereof) compromises patient safety, quality care, or is incongruent with the patient and community needs

Patient and community education question

I see that you are/were a member of [insert specific here]. Can you tell me about a project/situation that the committee addressed? How did the committee meet the needs of the patient/com-munity?

Patient advocate question

Can you recall a time that you had to advocate on behalf of a patient (or community)? What was the situation? What did you do? How did it turn out?

Score: 1 2 3 4 5

Strengths

Weaknesses





Organizational priorities*

Improved customer satisfaction scores

Goal: A professional who understands concepts of cus-tomer expectations, customer service, and customer satisfaction

Customer service question

Our patients and visitors are very important to us. It is our goal to exceed their expectations.

Can you tell me about a time that you exceeded a customer’s expectations?

Can you recall a time when a patient or his or her family member was not satisfied with an aspect of the patient’s care? How did you know he or she was not satisfied? What did you do to rectify the situation? What was the outcome?

Score: 1 2 3 4 5

Strengths

Weaknesses

Organizational priorities*

Patient-centered care

Goal: A professional who consistently invites patients and families to participate and collaborate in the care planning process

At our organization, we believe that collaboration with patients and families is essential.

Tell me about a time when you partnered with a patient and his or her family to provide care that met their needs. Please describe the situation. What was the outcome?

Score: 1 2 3 4 5

Strengths

Weaknesses

*Will vary by organization. A few examples are highlighted in this document.

Source: Adapted from Nursing Orientation Program Builder: Tools for a Successful New Hire Program. HCPro, Inc.



CASE STUDY IN RETENTION

CASE 1

The Academy Awards for Nursing Excellence

On every ordinary day, nurses perform extraordinary service. The CNO of Grady Health System in Atlanta wanted to recognize nurses for this achievement, so Rhonda Scott, PhD, RN, created a five-star event—the Academy Awards for Nursing Excellence—to celebrate staff nurses’ outstanding performance and practice.

Grady Health has been working toward creating an environment that reflects the 14 Forces of Magnetism by implementing a shared governance model, improving the image of nursing, and focusing on nurse-to-patient ratios. “We are doing all the quality expectations that go along with having an ANCC Magnet [Recognition Program® status] environment, and with this I wanted to make sure we recognized our nurses,” says Scott. “We put a lot of reward and recognition activities in place with our Critical Care Nurse of the Year, Perinatal Nurse of the Quarter, and DAISY (Diseases Attacking the Immune System) Award, but our most anticipated event is our Academy Awards for Nursing Excellence.”

Nominating the champions

Grady Health is a public institution, so funds for the recognition awards were raised and donated through the hospital’s foundation. In-house marketing involved save-the-date cards, flyers, posters, and brochures that were distributed throughout the hospital and to the foundation’s contact list to find sponsors.

Scott created nomination forms that were distributed on every unit and anyone at Grady could nominate a staff nurse, even family members. The forms asked four questions:

1. What is the nurse’s role at Grady?

2. Tell us why you think this nurse role-models nursing excellence.

3. What has this nurse done to contribute to the nursing profession (e.g., involvement in associations, national organizations, or local chapters)?

4. What else about this nurse makes him or her excellent? (For example, one nurse at Grady taught CPR to a Boy Scout group.)

Nurses could be nominated in several categories:

• LPN

• APN

continued



• Community Service

• Education and Teaching

• Nursing Leadership

• Clinical Care

Awards were also given to nurses with outstanding contributions in ambulatory, critical care, emergency, long-term care, med-surg, oncology, perinatal, perioperative, psychiatric/mental health, and surgical areas.

Tallying the votes

More than 200 nominations were received and distributed to 10 judges for review. The judges included a pharmacist, a nutritionist, a case management social worker, unit directors, and a businessperson from the community who was familiar with Grady nurses. Nominees’ names were obscured on the forms so that the judges did not know who they were reading about, and each of the four answers from the preceding questions was individually scored. Each nominee had to be a staff nurse at Grady for two years and a full-time employee in good standing for his or her nomination to be reviewed.

Scott wanted an objective tallying of the votes, so she sent the scores to an accounting firm to be totaled. “I always want our nurses to be able to trust the integrity of this program and really believe that everyone has a chance of winning based on what they bring to the table in terms of excellence,” she says. The accounting firm certified the top three finalists and the winner in each category. Out of 239 nominations, the list was narrowed to 37 finalists. Scott knew who the three finalists were for each category, so she filmed them working and took a picture for the program booklet.

Rolling out the red carpet

The 37 finalists and their guests had free admission to the awards ceremony at The Four Seasons Atlanta Hotel, whereas other attendees paid $100 for their tickets. Scott had hoped that 250 people would attend, but the event was so popular that almost 300 people attended. “A few of our physicians even wrote checks for $1,000 and told me to send 10 nurses from their unit to the awards ceremony,” says Scott.

The finalists and their guests enjoyed a cocktail hour until the ballroom doors opened for the finalists to triumphantly parade in, accompanied by Tina Turner’s song “Simply the

CASE STUDY IN RETENTION (CONT.)

CASE 1



CASE STUDY IN RETENTION (CONT.)

CASE 1

Best.” The event was a glittering occasion, and guests wore formal attire, which perfectly suited the red carpet that was rolled out in the ballroom and the lavish five-course meal. After dinner, the finalists were escorted down the red carpet by tuxedo-dressed chief nurses from each unit the finalist represented. “I told Dr. Scott that I have been a nurse at Grady since 1968, and I don’t ever remember nursing being honored,” says Angelle Vuchetich, RN, CANP, manager of the infectious disease program, and winner for outstanding contributions in advanced practice nursing. “Being honored as a Grady nurse is exciting!”

The event also featured a video of all 37 finalists stating why they enjoy being a nurse at Grady, as well as a slide show of the nurses in their work environment. Following a drum roll, Scott opened the sealed envelopes where the winners’ names had been written in gold ink.

“When we announced the critical care winner she began to hyperventilate and couldn’t get out of her chair to come on stage,” says Scott. “I thought she was going to pass out!” The overall winners of each category received a personalized glass trophy, flowers, and $500, which came from the funds that were raised. The runners-up received a plaque and a bouquet of flowers. Scott had each winner make a speech and the critical care winner could hardly speak because she was emotional, says Scott. “She had the whole room in tears; the overall speeches were priceless.” After the awards ceremony, everyone took to the dance floor until midnight when the ballroom doors closed.

Source: Nurse Retention Toolkit: Everyday Ways to Recognize and Reward Nurses, copyright HCPro, Inc.



Nurse leaders in the greater Dallas-Fort Worth, Texas metropolitan area began a community recognition award more than 25 years ago. The Great 100 Nurses originally stemmed from an idea by P.K. Scheerle, a registered nurse and successful entrepreneur, who founded a similar event to recognize nurses in New Orleans, Louisiana. In 1991, a small group of nursing leaders, Beth Mancini, PhD, RN, Sarah Moody, DNP, RN, NEA-BC, Lucy Norris, MS, RN, CENP and Judy Denison, MS, RN, NEA-BC, worked with the community and local nursing organizations to create the DFW Great 100 Nurses.

The Great 100 celebration raises the awareness of the contributions of nurses to patient care, research, leadership, education and community service of more than 50,000 nurses practicing in the DFW area. In addition, the celebration builds the image of nursing through positive reinforcement of the profession as a scientific art and the recognition of those who exemplify excellence.

It is a special honor for a nurse to be nominated by family members, patients, peers, former teachers, physicians, and administrators. Over the past twenty-seven years, this award has become recognized throughout the nursing community in the Dallas/Fort Worth metroplex as an esteemed honor and prestigious accomplishment.

What begin as a recognition event quickly became a source of not only individual but organizational pride, given the competitive nature of this large urban environment, nurse executives, leaders, and direct care staff alike. The community has embraced this opportunity to recognize and celebrate the accomplishments of nurses in all roles.

Each year 100 “GREAT” nurses are selected to receive this honor at a ceremony attended by leaders, colleagues, friends, and family using the following criteria:

• Nominees must be Registered Nurses who live in the DFW metroplex

• The nomination letter should not include the nominee’s name or specific identifications about the Registered Nurse (e.g., place of employment).

• The letter of recommendation MUST address each of the following categories:

– ROLE MODEL,

– LEADERSHIP QUALITIES,

– SERVICE TO THE COMMUNITY,

– COMPASSIONATE CAREGIVER, and

CASE 2

DFW GREAT 100 NURSES CASE



CASE 2

DFW GREAT 100 NURSES CASE

– SIGNIFICANT CONTRIBUTIONS.

• • Past Great 100 recipients are not eligible to be re-nominated.

Selection Process

The Great 100 Nurses are selected by a group of peers that are previous Great 100 honorees. The nominations are blinded and double reviewed using a consistent scoring mechanism. The scores are compared, and the 100 highest scoring nominations are selected.

The Celebration

The Great 100 Nurses attend an event that includes a reception, dinner and award ceremony at the Morton H. Meyerson Symphony Center in Dallas, Texas. In the ceremony these Great 100 Nurses receive a pin, certificate and rose with the opportunity to walk across the stage of the symphony center to thunderous applause, accompanied by cheers. Leaders and colleagues from recipients’ organizations often accompany those applause and cheers with noisemakers, signs and banners, reflecting their recognition and support for their “Great 100 Nurse” colleagues.

While knowing that their peers or leaders nominated them to receive such an honor is meaningful and that they were selected from hundreds of nominations is rewarding enough, but the loud cheering and support from their leaders and team members that takes place at this event certainly plays an important role in fostering recipients’ loyalty to

their colleagues, their leaders, and their organizations.

You can visit the website at http://www.dfwgreat100nurses.com/ to learn more about this incredible community event and download a copy of the start-up manual to find implementation strategies.



INCENTIVES INDEX

Compensation-related incentives How important is this incentive to you?

Not (1) ↔ Very (10)

Place a 4 next to

your TOP 3

ON-CALL PAY: Paid time while away from hospital but able to be contacted and come back to work immediately.

1-2-3-4-5-6-7-8-9-10

SHIFT DIFFERENTIAL: Extra hourly pay for working the evening or night shift.

1-2-3-4-5-6-7-8-9-10

PREMIUM PAY: Time and a half or double time pay for working weekends or holidays – not overtime.

1-2-3-4-5-6-7-8-9-10

OVERTIME PAY: Time and a half or double time pay for working more than scheduled hours per day or week.

1-2-3-4-5-6-7-8-9-10

PAID TIME OFF: Paid leave day taken at regular pay, on a day of your choice.

1-2-3-4-5-6-7-8-9-10

VACATION: Paid time off at regular pay, not related to illness, on a day of your choice.

1-2-3-4-5-6-7-8-9-10

RETIREMENT PAY: Monies added to a 401K or other retirement plan to be accessed at age 65.

1-2-3-4-5-6-7-8-9-10

TUITION REIMBURSEMENT: Loan payment, tuition, or textbook assistance, paid directly to the school or university or reimbursed to you with receipts at the end of a semester or program.

1-2-3-4-5-6-7-8-9-10

TOOL 2

PROFIT SHARING: Specific amount of money paid at one time in recognition of the hospital achieving income goals or resulting from unexpected profits.

1-2-3-4-5-6-7-8-9-10

BONUS: Specific one-time payment to reward actions or participation in hospital projects resulting in positive outcomes for the hospital.

1-2-3-4-5-6-7-8-9-10

MERIT PAY: Salary increase related to meeting specific preidentified goals or benchmarks based on supervisor evaluation.

1-2-3-4-5-6-7-8-9-10

HIRE-ON BONUS: Lump-sum bonus for signing a contract to come to work at a particular hospital.

1-2-3-4-5-6-7-8-9-10

RETENTION BONUS: Lump-sum bonus for continuing to work at a hospital, given after a defined period of continuous service.

1-2-3-4-5-6-7-8-9-10

REFERRAL BONUS: Lump-sum payment given when a nurse you referred to the hospital signs a contract to work for the hospital.

1-2-3-4-5-6-7-8-9-10

MEDICAL BENEFITS: Insurance and paid sick time off for illness of self, spouse, and/or family.

1-2-3-4-5-6-7-8-9-10



continued


EDUCATION – CAREER DEVELOPMENT – CONTINUING EDUCATION: Classes to enhance your skills, given on hospital time at no charge to you.

1-2-3-4-5-6-7-8-9-10

EDUCATION RELEASE TIME: Paid time to attend off-site continuing education seminars or organizational conferences to enhance skills.

1-2-3-4-5-6-7-8-9-10

SUBSIDIZED TRANSPORTATION: Free van pools or free parking; gasoline stipend paid monthly or quarterly.

1-2-3-4-5-6-7-8-9-10

LUXURY ITEM INCENTIVES: Nonmonetary items, such as cruises, jewelry, or entertainment tickets, given in recognition of superior achievement.

1-2-3-4-5-6-7-8-9-10

SUBSIDIZED DAY CARE OR ELDER CARE: On-site or near-site reputable and affordable day care for preschool children, after-school care for school-age children, or day care for dependent elderly relatives.

1-2-3-4-5-6-7-8-9-10

Nonmonetary incentives How important is each of these items to you?

PERSONAL ATTENTION FROM YOUR MANAGER: Face time or emails about your needs, goals, and feedback on your performance.

1-2-3-4-5-6-7-8-9-10

PERSONAL RECOGNITION FROM MANAGER/SUPERVISOR: Written or oral recognition and congratulations for excellence or achievement.

1-2-3-4-5-6-7-8-9-10

OPPORTUNITY TO SOCIALIZE WITH COWORKERS: Pleasant working conditions where you work with people you like and who like you.

1-2-3-4-5-6-7-8-9-10

COHESIVE WORK ENVIRONMENT: Working with people who help you, share the work, and pull together as a team.

1-2-3-4-5-6-7-8-9-10

AVAILABILITY OF COMPRESSED SHIFTS: Working 32/40 or 36/40.

1-2-3-4-5-6-7-8-9-10

SHIFT OF YOUR CHOICE: Ability to have total choice in the shift(s) you work.

1-2-3-4-5-6-7-8-9-10

SELF-SCHEDULING: The manager allows nurses to select their own shift given certain parameters or bid on shifts.

1-2-3-4-5-6-7-8-9-10

OTHER SPECIAL INCENTIVES: Such as an employee concierge service, employee discounts, or meal vouchers.

1-2-3-4-5-6-7-8-9-10

MAGNET STATUS: Hospital is recognized by ANCC as a desirable place for nurses to work though designation as a Magnet Hospital.

1-2-3-4-5-6-7-8-9-10

RELAXED DRESS CODE: Nurses allowed to wear scrubs or uniforms of choice as long as professionalism is maintained.

1-2-3-4-5-6-7-8-9-10

INCENTIVES INDEX (CONT .)TOOL 2



SCORING:

Higher scores = More important. Identify the top 5 or 10 incentives for your unit.

Wieck KL, Dols J, & Northam S. 2009. “What nurses want: The Nurse Retention Project.”

Nursing Economics 27(2):169–177.

Source: Managing the Intergenerational Nursing Team, copyright HCPro, Inc.

INCENTIVES INDEX (CONT .)TOOL 2



SEEKING EMPLOYEE FEEDBACKTOOL 3

1. Name something that could be done to make your unit work environment better.

2. What is one thing on your wish list that the organization could offer its employees that is not currently offered?

3. What is the one most important thing that keeps you here?

4. What are the two most common reasons people leave our unit or the organization?

5. What benefit do you value most and hope the organization does not eliminate?

6. Do you believe you and your peers have input into unit decisions that affect patient care?

7. Do you believe you and your peers have input into decisions that affect your work environment?

8. Do you believe team members on your unit/in your organization are recognized for their contributions?

9. Are diverse opinions and ways of doing things valued on your unit and in the organization?

10. Do you believe healthy work-life balance is promoted and valued by leaders in the organization?

100 Winners Circle, Suite 300Brentwood, TN 37027www.hcmarketplace.com



With the current nursing shortage, recruiting and retaining the best nurses has implications for all levels of practice and all care delivery settings. Nurse Manager’s Guide to Retention and Recruitment is a user-friendly guide for nurse leaders that provides sound theoretical perspectives, evidence-based practices, practical strategies, and tools for achieving the best recruitment, engagement, and retention outcomes for their organization.

In addition, this book includes examples gleaned from the authors’ collective years of experience and expertise in a complex urban healthcare market with large for-profit, not-for-profit, and public (county, state, and federally funded) healthcare organizations and systems.

Build and retain a high-performing nursing team through:

• Current evidence-based practice and expert opinion from • successful nursing leaders • Case studies and interactive problem-solving scenarios • Extensive bibliographies, appendixes, and additional • resources for further education

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